Healthcare Provider Details

I. General information

NPI: 1629022397
Provider Name (Legal Business Name): THOMAS JAMES HEINITZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 12/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 S BOUNDARY AVE ESSENTIA HEALTH PROCTOR CLINIC
PROCTOR MN
55810-2306
US

IV. Provider business mailing address

211 S BOUNDARY AVE ESSENTIA HEALTH PROCTOR CLINIC
PROCTOR MN
55810-2306
US

V. Phone/Fax

Practice location:
  • Phone: 218-576-0200
  • Fax: 218-624-7323
Mailing address:
  • Phone: 218-576-0200
  • Fax: 218-624-7323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number41634
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: